Pediatric Vomiting

Vomiting, or emesis, is the forceful oral expulsion of gastric contents. Vomiting is a common presenting symptom in pediatrics. The frequency and characteristics of vomiting may point toward a specific pathology, just as its presence can be another symptom of a greater clinical situation. The majority of vomiting symptoms are benign and self-limited. A good history and physical examination can bring into focus the underlying cause and workup. Management is with antiemetics Antiemetics Antiemetics are medications used to treat and/or prevent nausea and vomiting. These drugs act on different target receptors. The main classes include benzodiazepines, corticosteroids, atypical antipsychotics, cannabinoids, and antagonists of the following receptors: serotonin, dopamine, and muscarinic and neurokinin receptors. Antiemetics and treating the underlying cause, if needed. The most common complications are dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration and malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Definition and Etiology

Definition

Vomiting (emesis) refers to the forceful oral expulsion of gastric contents.

Etiology

  • Newborns:
    • Esophageal atresia Esophageal atresia Esophageal atresia is a congenital anomaly in which the upper esophagus is separated from the lower esophagus and ends in a blind pouch. The condition may be isolated or associated with tracheoesophageal fistula, which is an abnormal connection between the trachea and esophagus. Esophageal Atresia and Tracheoesophageal Fistula
    • Vascular rings Vascular rings Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Vascular Rings
    • CNS lesions
  • Infants:
    • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis
    • Pyloric stenosis
    • GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease
    • Food allergies
    • Milk-protein intolerance
    • Overfeeding
    • Inborn errors of metabolism
    • Vascular rings Vascular rings Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Vascular Rings
  • Children and adolescents:
    • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis
    • Pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess
    • Systemic infection
    • Toxic ingestions
    • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
    • Ulcers
    • Pancreatitis
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care

Clinical Presentation

History

A complete history should be elicited to narrow the differential diagnosis of vomiting in a child.

  • Demographics:
    • Age
    • Sex
    • Place of residence (important in cases of epidemics and food poisoning)
  • Onset/duration/progress of symptoms
  • Association of food intake
  • Fluid balance:
    • Number of wet diapers/urinations per day
    • Increase in drinking or asking for water
  • Associated symptoms:
    • Fever
    • Earache
    • Headache
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
    • Chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain (referred heartburn in esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis)
  • Nature of the vomitus:
    • Projectile/nonprojectile
    • Color
    • Contents
    • Painful/painless
    • Hematemesis can occur in:
      • Mallory–Weiss syndrome (indicating forceful vomiting)
      • Coagulopathies
    • Severe, persistent vomiting in cases of:
      • CNS compromise ( meningitis in children Meningitis in Children Meningitis is inflammation of the meninges around the brain and spinal cord. The majority of cases occur during childhood and are predominantly viral or bacterial in etiology. Clinical presentation is influenced by the age of the child and the causative pathogen, but meningitis typically presents with signs of meningeal irritation, fever, and lethargy. Meningitis in Children, hydrocephalus)
      • Metabolic derangement
      • Chemotherapy-induced
    • Sexual activity in adolescent girls (for potential pregnancy-induced vomiting)

Physical examination

  • Fever in GI and CNS infections
  • Bulging or sunken fontanelle:
    • Bulging (↑ intracranial pressure)
    • Sunken ( dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration)
  • Poor feeding
  • Signs of dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration or shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock ( fluid replacement therapy in children Fluid replacement therapy in children Children are particularly vulnerable to developing dehydration because they have higher insensible water loss and more elevated metabolic rates than adults. In addition, children's inability to communicate their needs compounds with large losses of fluids (e.g., diarrhea, vomiting), putting them at even higher risk. Fluid Replacement Therapy in Children)
  • Low height and weight for age in cases of anorexia due to loss of calories and nutrients:
    • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive
    • Malnutrition
  • Nystagmus in vestibular disorders ( vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo)
  • Marked abdominal distention and tenderness in appendicitis or acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen
  • Presumptive signs of pregnancy
Table: Degree of dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration in children
Mild Moderate Severe
Weight loss
  • < 5% in infants
  • < 3% in older children
  • 5%–10% in infants
  • 3%–9% in older children
  • > 10% in infants
  • > 9% in older children
Dry mucosa (first sign) +/– (looks dry) + (looks parched)
Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin turgor (last sign) + +/– – (tenting)
Anterior fontanelle depression + +/++
Mental status Normal Fatigued/irritable Apathy/lethargy
Enophthalmos + +
Breathing Normal Deep, maybe tachypneic Deep and tachypneic
Heart rate Normal Increased Very high
Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension + +
Distal perfusion Normal
  • Feels cold
  • 3–4 sec
  • Acrocyanotic
  • > 4 sec
Urinary output Decreased Oliguria Oliguria/anuria
Table: Characteristics of vomitus according to level of obstruction
Nature of vomitus Approximate level of obstruction
Nonbilious acidic vomitus Distal to stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach, proximal to duodenum
Bilious vomiting Distal to 2nd part of duodenum
Feculent vomitus Obstruction in the large bowel
Nondigested food content Proximal obstruction

Diagnosis and Management

Laboratory testing

  • Basic metabolic panel: 
    • In cases of severe dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration can show: 
      • ↓ Glucose
      • ↑ BUN
      • ↑ Sodium and chloride
      • ↓ Bicarbonate
      • ↑ Creatinine
  • CK: 
    • When concerned about rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis
    • Elevated in severe dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration

Pharmacologic therapy

  • IV hydration for:
    •  Hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Severe dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration
    • Intractable vomiting
  • Antiemetics:
    • Ondansetron IV or oral (first line)
    • Metoclopramide oral or IV
    • Dimenhydrinate orally (in motion sickness for ages 12 and up)

Nonpharmacologic therapy

  • Oral rehydration (preferred and is first line in mild or moderate dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration)
  • Surgical intervention for intestinal obstructions (i.e., pyloric stenosis)
  • Proton pump inhibitors (PPI) in peptic disease (i.e., gastroesophageal reflux disease Gastroesophageal Reflux Disease Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease)

Mild to moderate dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration

  • Oral rehydration therapy (ORT) is first-line treatment in mild or moderate dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration.
  • Oral rehydration solutions with electrolyte contents similar to those of fluid lost should be used:
    • E.g., Pedialyte or Enfalyte
    • Breast-fed infants should continue to nurse
  • Goal: Provide 50–100 mL/kg of fluids over 2–4 hours. Route of administration depends on patient age and frailty:
    • Syringe or spoon-feeding
    • NG tube
  • +/– Ondansetron to prevent vomiting
  • Clinical hydration status should be monitored frequently.
  • Failure to improve with ORT should prompt IV hydration.

Severe dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration

Severe dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration can cause hypoperfusion of the brain and vital organs and is considered a medical emergency to be addressed rapidly.

  • Acute resuscitation phase:
    • Goal: correct or prevent hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Rapid volume expansion through fluid boluses:
      • 20 mL/kg given over 20 minutes.
      • Can be repeated up to 3 times
      • Monitor vital signs between each bolus.
    • Choice of replacement fluid:
      • Isotonic fluids only
      • Either lactated Ringer’s or normal saline is appropriate.
    • Glucose monitoring:
      • Point-of-care monitoring for hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
      • IV glucose should be administered.
      • 5–10 mL/kg of 10% dextrose in normal saline OR 2–4 mL/kg of 25% dextrose in normal saline
  • Resuscitation phase:
    • Slower replacement of lost fluids over 24 hours
    • Total fluid for resuscitation phase = maintenance fluids + (rehydration – bolus already given)
    • Rehydration is divided into 2 phases:
      • 50% over 1st 8 hours
      • 50% over next 16 hours
    • 5% dextrose with 0.2% sodium chloride compensates for maintenance requirement of sodium in most children
  • After 24 hours if clinically stable → continue maintenance fluids

Volume replacement calculations

  • Standard bolus:
    • 20 mL/kg/20 minutes
    • Up to 3 times
    • Monitor vital signs.
  • Maintenance calculations:
    • 4-2-1 rule:
      • 1st 10 kg = 4 mL/kg/hour
      • 2nd 10 kg = 2 mL/kg/hour
      • Additional kg = 1 mL/kg/hour
    • Example: For a child who weighs 37 kg:
      • (10 kg × 4 mL/kg/hour) + (10 kg × 2 mL/kg/hour) + (17 kg × 1 mL/kg/hour) =
      • (40 mL/hour) + (20 mL/hour) + (17 mL/hour) = 77 mL/hour
  • Rehydration is calculated by weight and severity of dehydration Dehydration Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume Depletion and Dehydration:
    • Amount calculated is added to maintenance amount, spread throughout the day.
    • < 10 kg:
      • Mild: 50 mL/kg/day
      • Moderate: 100 mL/kg/day
      • Severe: 150 mL/kg/day
    • ≥ 10 kg:
      • Mild: 30 mL/kg/day
      • Moderate: 60 mL/kg/day
      • Severe: 90 mL/kg/day

Complications

  • Dehydration
  • Malnutrition
  • Esophagitis
  • Intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception
  • Sigmoid volvulus Volvulus A volvulus is the twisting or axial rotation of a portion of the bowel around its mesentery. The most common site of volvulus in adults is the colon; most frequently the sigmoid volvulus. Patients typically present with symptoms of bowel obstruction such as abdominal pain, distension, vomiting, and constipation/obstipation. Volvulus
  • Reflux

Related videos

References:

  1. Maqbool, A., Liacouras, C. A. (2020). Major symptoms and signs of digestive tract disorders. In Kliegman, R.M., et al. (Eds.). Nelson textbook of pediatrics, pp. 1902.e.1–1912.e1. Retrieved March 24, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501003321
  2. CDC. (2015). Diarrhea: Common illness, global killer. https://www.cdc.gov/healthywater/global/diarrhea-burden.html 
  3. King, C.K., Glass, R., Bresee, J.S., Duggan, C. (2003). Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 52(RR-16):1–16. https://pubmed.ncbi.nlm.nih.gov/14627948/
  4. Lorenzo, C. (2020). Approach to the infant or child with nausea and vomiting. UpToDate. Retrieved March 27, 2021, from: https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-nausea-and-vomiting
  5. Mullen, N. (2009). Vomiting in the pediatric age group. Pediatr Health 3(5):479–503. https://www.medscape.com/viewarticle/711641

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